Fears that hospitals are covering up death rates

New data triggers fears that hospitals are 'fiddling the figures' on hospital
deaths by increasing the number of deaths recorded as 'palliative' - classed
as expected because a patient was terminally ill. Hover over the chart or
table for more detail on a trust

Hospitals have been accused of “fiddling” their death rate figures by claiming patients were terminally ill, after new figures showing dramatic changes in the way mortality is recorded.

The NHS data shows a five-fold rise in the proportion of deaths being “coded” so that they barely count towards hospital mortality statistics - with some trusts now recording one in three deaths as a “palliative” case.

Last night experts said they were troubled by the “deeply concerning” trends, fearing hospitals could be hiding the fact patients had suffered poor care which contributed to their death.

They said the scale of the misreporting was such that it could even hide “another Mid Staffs” scandal.

Every NHS hospital has to collect and publish data showing how its death rates compare with what would be expected.

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Crucially, if a case is coded as “palliative” it barely counts towards the rate, because it is classed as an expected death.

The code is only supposed to be used when a patient’s death in hospital is an inevitable consequence of their condition - such as that from a terminal illness.

Now new figures have triggered concern that the code is in fact being used to disguise many more deaths.

Data from health analysts Dr Foster shows that, across England in 2012/13, 36,425 deaths were coded as palliative. That was 17.3 per cent of the total number of deaths - twice the number recorded in 2008 and five times the 3.3 per cent of deaths recorded in 2006.

Roger Taylor, director of research at healthcare analysts Dr Foster Intelligence, which produced the data, said there were “real concerns around the gaming of indicators”, adding: “Whether or not you are doing it deliberately, the end result is that the variation in coding may disguise poor outcomes.”

He said: “The trends we are seeing are troubling - they are deeply concerning. Poor quality data is harming patients because you can’t see where things are going wrong. If the data is not being recorded consistently and, moreover, if that isn’t picked up because of a lack of auditing there is a risk that poor patient care is being disguised, and the public misled.”

Experts said that in some cases, patients were being counted as “palliative cases” when they had been admitted to hospital for a broken hip, but failed to recover.

Mr Taylor said he had called repeatedly on NHS officials to tighten the rules, and to audit such data, so that trusts could not manipulate it, but said nothing had been done.

“We’re worried this issue is not being given sufficient priority,” he said. “The bottom line is it could increase the possibility of failing to identify another Mid Staffs and potentially cost lives.”

Joyce Robins, from Patient Concern, said: “Hospitals are clearly fiddling these figures and that frightens me. Hospitals are just not open enough to admit what is happening - instead they dream new ways to disguise it. All the talk of transparency is just that - talk.”

Prof Sir Brian Jarman, Emeritus Professor of Imperial College London, an expert on mortality data, said: “I don’t think these very extreme changes reflect reality. I don’t think these hospitals have transformed into hospices to treat the dying overnight.”

Figures show that among the 20 NHS trusts with the steepest rise in palliative coding, between 2008 and 2012, 17 reduced their published death rate at the same time.

At East and North Hertfordshire trust the proportion of deaths which were explained as “palliative” quadrupled - from 9.92 per cent in 2008 to 43.25 per cent in 2012.

Over the same time, the trust’s death rate fell from 14 per cent higher than would be expected, to 3 per cent below.

At North Middlesex University Hospital trust the proportion of deaths coded “palliative” rose from 4.76 per cent to 31.48 per cent, the analysis shows.

Meanwhile, death rates fell from 6.8 per cent higher than expected to 12.2 per cent below.

At Guy’s and St Thomas’ NHS Foundation trust, the percentage rose from 1.18 per cent to 31.65 per cent.

At Kings College Hospital Foundation trust it rose from 8.71 per cent to 38.36 per cent, while at Royal Liverpool and Broadgreen University Hospitals NHS trust, the percentage rose from 1.35 per cent to 29.23 per cent.

Gary Walker, a former NHS trust chief executive who lost his job after raising concerns about patient safety, said the figures looked “very suspicious” warning: “In the NHS, if it looks like a trust is fiddling the numbers it probably is.”

Charlotte Leslie, a Conservative MP and member of the House of Commons health committee, said: “This is very worrying data. We already know that at the time of the Mid Staffs scandals, hospitals were fiddling the figures to massage their mortality rates.”

“These figures suggest that hospitals are still fiddling the figures to put their own reputation and that of their managers ahead of patient safety.

A Department of Health spokesman said: “The NHS needs high quality mortality data. We would expect that all NHS Trusts have robust auditing systems in place.”

East and North Hertfordshire trust said it was one of only a handful of hospital groups to run an NHS hospice and that a recent external reviews showed its coding was accurate.

North Middlesex University Hospital trust said the increase in deaths coded as palliative was due to better recording, as did Guy’s and St Thomas’ NHS Foundation trust which also said that as one of the largest providers of services for patients with cancer, it was to be expected that it would have higher than average rates of palliative coding.

Kings College Hospital Foundation trust said its rise was down to improvements recording palliative care. Royal Liverpool and Broadgreen University Hospitals NHS trust said it refuted any suggestion that changes were a result of any attempt to deliberately improve mortality rates, and said it coded palliative care patients with incurable diseases accurately.

In total, twenty trusts saw a rise of at least 17 percentage points in the number of deaths coded as palliative between 2008 and 2012, the statistics (listed in table above) show.

Ipswich Hospital said it its coding levels had been lower than average until a review of cases, which found too many patients in recepit of end-of-life care had not been properly recorded.

Buckinghamshire Healthcare NHS Trust said it had taken over the running of an 11-bedded hospice and that its palliative care team “work very closely with our acute wards and other inpatient community hospitals to ensure our end of life patients receive high quality care.”

Ashford and St Peter’s Hospitals foundation trust said the increase was a result of changes to palliative care coding criteria and improved record keeping and that it was “confident that our current data accurately reflects the trust’s specialiast palliative activity.”

The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust said “Unlike most acute hospitals in the country, we have a specialist palliative care unit – our Macmillan Unit – on site. Locally more patients will appropriately spend the end of their life in our hospital because of the presence of this hugely respected facility.”

Hinchingbrooke Health Care NHS Trust said it became aware it was under-reporting palliative care mortality in 2009, and employed a palliative care consultant to jointly carry out an audit of coding practices with Dr Foster, which led to changes.

James Paget University Hospitals Foundation trust said the increases in coding were historical, and that coding had been improved after an external audit found the trust was not recording palliative care coding in line with national guidance.

Epsom and St Helier University Hospitals Trust said: “The percentage rise in deaths coded as palliative care since 2008 reflects increased education and training of clinical staff to communicate appropriate end of life care plans for the dying patient and better documentation in the patient notes.”

Peterborough and Stamford Hospitals NHS Foundation Trust said its coding department “works extremely hard with our palliative care team to ensure that documentation is clearly marked” and had improved the accruacy of its data, which accounted for the change.

Sandwell and West Birmingham Hospitals trust said it “has embarked on a programme of work systematically looking at the causes of death in hospital which has resulted in a substantial reduction in avoidable mortality.”